Chronic migraine and bilateral occlusion of the middle meningeal artery

BackgroundMigraine is the most common neurological problem in primary care affecting 18% of women and 6% of men, while chronic migraine affects 2% of the population and refractory migraine is estimated to affect between 5% and 30% of migraine sufferers. The dura is a well-vascularized structure, which is densely innervated by pain fibers. Intra-arterial administration of lidocaine in the middle meningeal artery (MMA) has been used for refractory migraine, promoting pain relief. Patients with chronic headaches who underwent embolization of the MMA for the prevention of chronic subdural hematoma recurrence experienced complete resolution of pain.MethodsBased on this data, we treated 10 patients consecutively with chronic and refractory migraine with a high degree of disability assessed by headache impact test (HIT-6) who experimented with pain relief with lidocaine injection and subsequently underwent definitive bilateral occlusion of the MMA with biological glue.ResultsMean age was 48.2 ± 14.4, with 90% being female, all patients confirmed primary headache in the lidocaine suppression test (LST) and after bilateral occlusion was observed worsening of pain between 0 h and 6 h (-0.9 (95% CI -2.2-0.6, P = 0.193) with complete improvement at discharge within 24 h. In the 30-day follow-up, we observed a significant improvement in HIT-6, 30.5 (95% CI 25.5-35.5, P < 0.001) that lasted up to 6 months. No neurological or technical complications were observed.ConclusionsPatients with chronic or refractory migraine, rigorously selected through the LST, may benefit from bilateral occlusion of the MMA for a period of up to 6 months, without additional risks. Despite the positive results, we must emphasize the preliminary nature of these findings, especially given the small sample size. A multicenter, randomized study is needed to prove the efficacy and safety of this new treatment and it may be an alternative for a specific subset of patients.